Everyday preparation pays off: Joint Commission accredits YNHH
The Joint Commission complimented the Psychiatric Hospital for reducing the use of restraints and its use of interdisciplinary treatment plans. The YNHPH Quality and Safety Committee, representing units on both campuses, worked on these and other issues. Members of the committee are (l-r): Merlyn LaPaix, RN, MSN, director, Psychiatric Nursing; Erik Sauer, RN, Adolescent Unit; Hadizah Collins, RN, Adult Inpatient; Pam Mathews, RN, Adult Inpatient (SRC); Corey Richmond, RN, APSM, Adult and Geriatric Unit; Violet Bauks, RN, APSM, Adult Inpatient; Sammie Lim, RN, Dual Diagnosis; Joyce Gambrell-Jones, RN, PSM, Adolescent, Geriatric, Adult units; and Gina Morrow, PharmD, clinical pharmacy specialist, Pharmacy Services.
After more than one year of intense preparation on all inpatient campuses and all ambulatory sites of Yale-New Haven Hospital, The Joint Commission has fully accredited all programs of the hospital, Ambulatory Behavioral Health Intensive Outpatient and Partial Hospital programs, and the Smilow Boutique for durable home care medical equipment.
"This full accreditation is an outstanding achievement for every single employee of Yale-New Haven Hospital," said Richard D'Aquila, president and COO. "The surveyors were extremely complimentary of the depth and consistency of the care our staff, physicians and management team offer throughout all sites where YNHH provides care. The results of this comprehensive survey validate the hard work employees invest in making sure that exceptional quality care is delivered here every day."
D'Aquila also pointed out that the surveyors were impressed with the successful integration of the two hospitals. "They were also impressed with how well the two campuses had come together in only 16 months — something they rarely see," he said.
YNHH started off the New Year bright and early on Monday, Jan. 6 as 11 doctors, nurses and healthcare administrators from TJC fanned out on the first day to locations as diverse as the Medical Intensive Care Unit, the Adult ED, the HVC Procedural Center, pediatric units and the Branford Cardiac Rehabilitation Center.
During the five-day accreditation survey, the group of professionals exhaustively observed and graded units from Norwalk to Litchfield to Guilford, but the bulk of their work was centered at the hospital sites in New Haven. They surveyed 155 clinical units, services and departments for patient care, toured physical plants where they examined walls, smoke barriers and sprinklers, and the environment of care where they checked cleanliness, clutter and expired medications. The surveyors also conducted system tracers and closed record reviews so they could grade the hospital‘s processes and systems.
Victoria Dahl Vickers, RN, MBA, director, Accreditation, Safety and Regulatory Affairs, managed the preparation throughout YNHH for the crucial Joint Commission survey, the first since the Saint Raphael Campus integrated with YNHH.
"Continuous preparation for this accreditation required a tremendous amount of work for our staff on all campuses and in all ambulatory settings," pointed out Vickers. "All of our integration activities with committees, roles and responsibilities, performance improvement initiatives and the standardization of policies and practices have paid off. The Joint Commission surveyors recognized our efforts."
Areas where YNHH excelled on the survey included:
- In addition to the degree of practice standardization between campuses and on ambulatory sites, surveyors noted seamless patient transitions, effective hand-off communications and continuity of care.
- Surveyors found staff to be engaged, confident and eager to interact with them; they noted that staff openly shared best practices and their area's performance improvement activities.
- Surveyors complimented the care excellence of physicians, nurses and allied health.
- They also noted clinicians' ease of use and navigation of the Epic electronic medical record.
Vickers noted that work continues and pointed out opportunities for improvement, including:
- Scheduled maintenance documentation of life safety and environment of care activities
- Appropriate documentation in the medical record — in both the written and electronic formats
- Processes related to medication storage, advance directives and rotation of in-use inventory.
Since the last Joint Commission survey, Yale-New Haven has grown considerably outside the greater New Haven area. One surveyor noted that in only one week, she had logged more than 330 miles as she surveyed YNHH sites that now range from the Pediatric Specialty Center in Norwalk to the Smilow Cancer Care Center in Sharon to the Shoreline Medical Center in Guilford.
"Our hospital continues to grow and change, and yet our focus on patient safety and high-quality service is unwavering," says Vickers. "Our success with this Joint Commission survey was a total group effort — everyone was involved in ways large and small. We thank all employees for their continuous commitment and dedication to high-quality, patient-centered care; it is what makes us a destination hospital."